Cross-mapping of nursing diagnoses and interventions in decompensated heart failure

Abstract

Objective To map the terms recorded in medical records of patients with decompensated heart failure for nursing diagnoses and interventions from the NANDA International and Nursing Interventions Classification. Method This is an exploratory and descriptive research, carried out by a cross-mapping study. Data were collected from 107 medical records of a Hospital Institute in the city of Rio de Janeiro/Brazil, in a period between October 2017 to February 2019. The diagnoses and interventions mapped were assessed by four clinical experts. Data analysis was performed using the content validation index and the Fleiss Kappa. Results The most frequent nursing diagnoses were: risk for infection (74.8%), decreased cardiac output (55.1%) and excessive fluid volume (49.5%). The interventions were: vital signs monitoring (79.4%), fluid monitoring (72.9%) and positioning (52.3%). Conclusion The research mapped 32 titles of nursing diagnoses from NANDA-I and 21 nursing interventions from NIC. The diagnoses and interventions mapped will contribute to the quality of the nurses’ records and patient safety.

Cuidados de transição na assistência circulatória mecânica: experiência para uma prática de enfermagem avançada

“…The official discussion of advanced nursing practice has gained prominence in the last decade, especially through debates in professional nursing councils. Although this practice is not yet a common reality in hospital units in the country, it is highly desirable, especially considering that hospitalized patients with decompensated HF require special care guided by clinical judgment and precise decision-making (23) . APN is emerging as an area of practice in which the nurse plays a central role in the provision and coordination of specialized care.…”

Nursing diagnoses for people hospitalized with heart failure: an integrative review

“…DCO was considered the priority diagnosis in several studies ( 30 - 32 ) . Other international ( 21 , 23 , 28 ) and national studies have identified DCO as one of the most prevalent diagnoses in people hospitalized with HF ( 20 , 27 , 29 , 35 , 42 ) .…”

“…Finally, research carried out through cross-mapping, using 115 medical records of people with decompensated HF in a hospital specializing in cardiology, mapped DCO along with other diagnoses and NIC NI, such as monitoring vital signs, water monitoring and positioning, among the most prevalent ( 42 ) .…”

“…EFV is frequently documented for people with congestive symptoms ( 22 , 36 , 42 - 43 ) , showing a relationship with the hemodynamic profiles displayed in clinical assessment ( 34 ) , in addition to high accuracy by nurses who evaluated people with HF in the first 24 hours of hospitalization ( 35 ) . The most common clinical manifestations are attributed to respiratory distress and right ventricular overload ( 29 ) and are consistent with the study that identified dyspnea, orthopnea, edema, positive hepatojugular reflux, paroxysmal nocturnal dyspnea, pulmonary congestion and increased central venous pressure as the main DC in people with decompensated HF ( 21 ) .…”

“…O DE DCD foi considerado o diagnóstico prioritário em várias pesquisas ( 30 - 32 ) . Outros estudos internacionais ( 21 , 23 , 28 ) e nacionais identificaram o DE DCD como um dos diagnósticos mais prevalentes em pessoas hospitalizadas com IC ( 20 , 27 , 29 , 35 , 42 ) .…”